5/1/2018 Blood Pressure Assessment: Overview, Indications, Contraindications

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Blood Pressure Assessment

Updated: Jan 03, 2018
Author: Mityanand Ramnarine, MD, FACEP; Chief Editor: Eric H Yang, MD more...

OVERVIEW

Overview
Blood pressure assessment is an integral part of clinical practice. Routinely, a patient’s blood pressure
is obtained at every physical examination, including outpatient visits, at least daily when patients are
hospitalized, and before most medical procedures. Blood pressure measurements are obtained for a
wide variety of reasons, including screening for hypertension, assessing a person’s suitability for a
sport (see the Medscape Reference topic Sports Physicals) or certain occupations, estimating
cardiovascular risk (see the Medscape Reference topic Risk Factors for Coronary Artery Disease),
and determining risk for various medical procedures.

Blood pressure measurements are also obtained routinely when following a hypertensive patient to
assist with tailoring of medications and treatment of hypertension. Finally, blood pressure
measurements are crucial for identifying if a patient is in potential or actual clinical deterioration.

Two methods for measuring a blood pressure exist, the direct and indirect method. The direct method
is the criterion standard and consists of using an intra-arterial catheter to obtain a measurement. It is
used more commonly in the intensive care or operative settings. This method, however, is not
practical due to its invasiveness and its inability to be applied to large groups of asymptomatic
individuals for hypertension screening. [1]

Therefore, the indirect (noninvasive) method is typically used. The indirect method involves collapsing
the artery with an external cuff, providing an inexpensive and easily reproducible way to measure
blood pressure. The indirect method can be performed using a manual cuff and sphygmomanometer,
a manual cuff and doppler ultrasound, or with an automated oscillometric device. The manual method
requires auscultation of the blood pressure, whereas the automated system depends on oscillometric
devices.

With manual blood pressure measurements, both observer and methodological errors can occur.
Observer errors include digit preferences, inattention, overly rapid cuff deflation, and hearing deficits,
while methodological errors include not accounting for beat-to-beat variations in the pulses and
sequential rather than simultaneous comparisons. [2] Automated oscillometric devices remove the
observer errors that can occur with manual measurements but are not without faults. The inaccuracy
of the oscillometric devices has been criticized, and some concern exists that using these devices in
certain populations, such as hypotensive, hypertensive, trauma, or cardiac arrhythmia patients, can
lead to inappropriate management. [3]

For example, in one study, mean systolic and diastolic blood pressures were significantly greater
using a mercury manometer than automated oscillometric techniques. [4] These findings have
important clinical implications, as the oscillometric techniques may falsely indicate that a patient

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treated for hypertension is now normotensive and requires no further medication adjustment.
Regardless of these inaccuracies, automated oscillometric devices are used more frequently and
appear to be sufficiently accurate for most clinical uses. [3] Furthermore, automated devices may give
more accurate readings in the setting of patients with the syndrome of white-coat hypertension. [5]

Another key component of measuring a manual blood pressure is an understanding of the Korotkoff
phases. The Korotkoff phases have been classified as 5 phases with phases I, IV, and V integral to
obtaining an accurate blood pressure measurement. Descriptions of the 5 Korotkoff phases are
outlined in the table below.

Table 1. Korotkoff Phases (Open Table in a new window)

Description of sound Clinical implication

Phase Appearance of clear tapping

Correlates with systolic blood pressure
I sounds

Phase Sounds become softer and

No clinical significance
II longer

Phase Sounds become crisper and

No clinical significance
III louder

Phase Sounds become muffled and Correlates as alternate measure of diastolic blood
IV softer pressurea

Phase
V
Sounds disappear completely Correlates with diastolic blood pressureb

a Use as the diastolic pressure if the pressure at the initiation of phase V is 10 mmHg or greater
than the pressure at phase IV.
b Accepted as the standard level of diastolic blood pressure.

The Korotkoff sounds are believed to originate from a combination of turbulent blood flow and
oscillations of the arterial wall. Of note, some believe that using the Korotkoff sounds instead of direct
intra-arterial pressure typically gives lower systolic pressures, with one study finding a 25 mmHg
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difference between the 2 methods in some individuals. [6, 7] Furthermore, some disagreement exists
as to whether Korotkoff phase IV or V correlates more accurately with the diastolic blood pressure.
Typically, phase V is accepted as the diastolic pressure due to both the ease of identifying phase V
and the lower discrepancy between intra-arterial pressure measurements and pressures obtained
using phase V. [8] Phase IV, alternatively, is used to measure the diastolic pressure if a 10 mmHg or
greater difference exists between the initiation of phase IV and phase V. This may occur in cases of
high cardiac output or peripheral vasodilatation, children under 13 years old, or pregnant women.

Regardless of whether a manual or automated method is used, the blood pressure measurement is a
key part of clinical medicine. The following is a description of the indications, contraindications, and
techniques for obtaining a blood pressure using both manual and automated devices.

Guidelines
Recommendations from the Canadian Hypertension Education Program include measurement of
blood pressure using electronic (oscillometric) upper arm devices rather than auscultation for accurate
office blood pressure measurement, and, in patients with increased mean blood pressure (but <
180/110 mm Hg) on visit 1, use of ambulatory or home blood pressure monitoring before visit 2 to rule
out white coat hypertension. [9]

The U.S. Preventive Services Task Force recommends ambulatory blood pressure monitoring over
office-based monitoring as a better predictor of long-term cardiovascular outcomes. [10]

Indications
Indications for blood pressure measurement include the following:

Screening for hypertension

Following the effect of anti-hypertensive treatments in a patient to optimize their management

Assessing a person’s suitability for a sport or certain occupations

Estimation of cardiovascular risk

Determining for the risk of various medical procedures

Figuring out whether a patient is clinically deteriorating, or is at risk for it

Contraindications
Although no absolute contraindications to obtaining a blood pressure exist, various relative
contraindications exist in which caution should be used. Usually, one should avoid obtaining a blood
pressure in the same arm in which an arteriovenous fistula (such as used in hemodialysis) is present,
or where lymphadema exists. Furthermore, caution should be used if the patient is at high risk for
developing lymphedema (such as after lymph node dissection for treatment of breast cancer),
although evidence-based studies have not demonstrated an increased risk of lymphedema or arm
swelling with blood pressure measurements taken on the ipsilateral arm after breast cancer surgery.
[11]

If possible, one should also avoid checking blood pressure in the extremity with intravenous access. In
these instances, using the other arm is recommended; if bilateral arteriovenous fistulas or

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lymphedema exist, then obtaining a lower extremity blood pressure is recommended.

One should delay obtaining a blood pressure is if the patient has smoked, exercised, or had
caffeinated products or other stimulants prior to the measurement. Smoking 30 minutes before the
procedure can transiently elevate the blood pressure. Exercising before measuring the blood pressure
can lower the reading. Caffeine or other exogenous adrenergic stimulants taken before the
measurement can acutely raise the blood pressure reading.

Equipment
To obtain a blood pressure, one can use either a manual blood pressure cuff or an automated
oscillometric cuff. When obtaining a manual blood pressure, a stethoscope and blood pressure cuff
with a sphygmomanometer is required (see image below).

Standard aneroid blood pressure cuff and stethoscope.

Any standard stethoscope can be used to auscultate the Korotkoff sounds while measuring the blood
pressure. Although the bell of the stethoscope allows for more accurate auscultation, the diaphragm is
more routinely used because of ease of use. [1] When using an automated oscillometric cuff, a
stethoscope is not needed.

Manual blood pressure cuffs have either mercury or aneroid sphygmomanometers. Although mercury
sphygmomanometers are more accurate, they have become less common due to the toxic effects of
mercury spills. [12] Therefore, most blood pressure devices now contain aneroid sphygmomanometers,
and calibrating the aneroid sphygmomanometers against a mercury sphygmomanometer every 6
months is important. The aneroid sphygmomanometer consists of a bellow system connected to a
needle to indicate the pressure on a dial. If the readings between the mercury and aneroid
sphygmomanometers differ by more than 4 mmHg then recalibration is required. [1]

Automated oscillometric blood pressure measuring devices are now more commonly used due to their
ease of use and availability. The oscillometric devices obtain the systolic measurement by detecting

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oscillations on the lateral walls of the occluded artery as the cuff is deflated. The oscillations begin at
the level of systolic pressure. Of note, the measurements obtained from automated measuring devices
are typically lower than those obtained with manual devices.

Cuffs are available in numerous sizes, and obtaining a proper-sized cuff is essential. The length of the
blood pressure cuff bladder should be 80% and the width at least 40% of the circumference of the
upper arm. Pickering et al. recommend the following cuff sizes:

1. for arm circumferences of 22–26 cm, use a small adult cuff (12x22 cm)
2. for arm circumferences of 27–34 cm, use an adult cuff (16x30 cm)
3. for arm circumferences of 35–44 cm, use a large adult cuff (16x36 cm)
4. for arm circumferences of 45–52 cm, use an adult thigh cuff (16x42 cm). [8]

Measurements with an inappropriately small cuff may result in an overestimation of the true systolic
pressure. Conversely, those made with a large cuff can underestimate it.

If measuring blood pressure using a cuff and Doppler ultrasound, then you will need either an
ultrasound machine with doppler capabilities, or a hand-held vascular doppler.

Positioning
Participant positioning is vital to obtaining an accurate blood pressure. Before obtaining a blood
pressure, the participant should remain in a seated position for at least 5 minutes. During this time
they should be comfortable and relaxed in a chair with back support, legs should be uncrossed, and
feet should rest comfortably on the floor (see image below).

Patient position for manual blood pressure.

Once the examiner is ready to measure the blood pressure, the participant’s arm should be supported
comfortably at the level of the heart. Falsely elevated or lowered blood pressures may be obtained if
the arm is below or above the level of the heart, respectively. [13] The examiner should ensure that the
sphygmomanometer is visible to him/her and that they are also comfortably positioned (see image
below).

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Examiner position.

The blood pressure cuff should then be placed with the bladder midline over the brachial artery
pulsation. Ideally, no restrictive clothing should be on the participant’s arms. Rolling up the sleeve can
cause a tourniquet around the upper arm, thus falsifying the measurement. If possible, the lower end
of the cuff should be 2-3 cm above the antecubital fossa to minimize artifactual noise related to the
stethoscope touching the cuff.

Technique
The following steps for measuring a manual arterial blood pressure follow the recommendations of the
American Heart Association: [1]

Initially, before taking the blood pressure, the patient should remain seated and at rest for 5
minutes.

Consumption of caffeinated products such as coffee, cola, or tea should be avoided for at least
30 minutes prior to measuring the blood pressure. Additionally, activities such as smoking and
exercising 30 minutes prior to measuring the blood pressure should also be avoided.

Choose a standardized mercury or aneroid sphygmomanometer with an adequate cuff size

based on the patient's arm size (see Equipment section) and place it on either arm of the
patient. The stethoscope should be placed lightly over the brachial artery, about 2–3cm below
the edge of the cuff. If the stethoscope is pressed too firmly against the artery, it may cause
turbulence and the disappearance of sound, thus artificially reducing the diastolic pressure. [13]

While obtaining the blood pressure, neither the patient nor the person obtaining the blood
pressure should talk.

Inflate the cuff to a pressure of 30 mmHg above the level at which the radial pulse is no longer
palpable (see image below).

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Aneroid sphygmomanometer at level 30 mmHg above the level at which the radial pulse is no longer palpable.

While slowly deflating the cuff (approximately 2-3 mmHg per heartbeat), listen for Korotkoff
phase I while watching the blood pressure gauge. Korotkoff phase I can be identified by when
the first pulse is auscultated. This sound is clear, repetitive, and tapping in nature and often
coincides with the reappearance of a palpable pulse. Record the measurement from the
sphygmomanometer at which the sounds first appear; this represents the patient’s systolic blood
pressure (see the image below).

Aneroid sphygmomanometer at level of systolic blood pressure.

While watching the sphygmomanometer, continue to slowly deflate the cuff. Initially, an abrupt
soft, indistinct, muffling sound may be heard (Korotkoff phase IV). After this sound, continue
listening until the sounds disappear completely (Korotkoff phase V). Record the measurement
from the sphygmomanometer when Korotkoff phase V starts; this represents the patient’s
diastolic blood pressure. If there is a 10 mmHg or greater difference between Korotkoff phase IV
and phase V then the pressure reading at phase IV should be recorded as the diastolic blood
pressure. This may occur in cases of high cardiac output or peripheral vasodilatation, children

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under 13 years old, or pregnant women. After the last Korotkoff sound is heard, continue
deflating the cuff for another 10 mmHg to ensure that no further sounds are heard. Then deflate
the cuff and allow the patient to rest (see image below).

Aneroid sphygmomanometer at level of diastolic blood pressure.

Wait at least 30 seconds and repeat the previous 3 steps to obtain a second blood pressure
measurement. If the measurements have greater than a 5 mmHg difference, then readings
should continue until 2 consecutive stable measurements are obtained. An average of the 2
stable measurements should be recorded as the patient’s blood pressure.

Wait another 1-2 minutes and repeat steps 4-10 to measure the blood pressure in the patient’s
opposite arm. If a measurement discrepancy exists between the 2 arms, then the arm with the
highest measurement should be used.

When recording the blood pressure measurement, note not only the pressure but also which arm
was used, the arm position, and the cuff size used.

Alternatively, the blood pressure may be obtained using the thigh or the wrist. A thigh blood pressure
is typically obtained when an arm to leg gradient is suspected such as with aortic coarctation or if
there is a contraindication to upper extremity measurements. The wrist blood pressure is typically
obtained in obese patients, where it may be difficult to find an appropriately sized cuff for the arm or
thigh. The same measurement techniques are used for the leg and wrist as discussed above for the
arm. Of note, values obtained from thigh or wrist measurements may be higher than arm pressures
due to increased hydrostatic pressure related to the lower position of the thigh and wrist to the heart.
The accuracy of the wrist measurement can be improved by keeping the wrist at the level of the heart.

When measuring a blood pressure using an automated oscillometric blood pressure device:

Initially, before taking the blood pressure, the patient should remain seated and at rest for 5
minutes.

Consumption of caffeinated products such as coffee, cola, or tea should be avoided for at least
30 minutes prior to measuring the blood pressure. Additionally, activities such as smoking and
exercising 30 minutes prior to measuring the blood pressure should be avoided.

Place the automated oscillometric cuff on either the right or left arm of the patient. Ensure that
the cuff is the appropriate size (see the Equipment section).
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While obtaining the blood pressure, neither the patient nor the person obtaining the blood
pressure should talk.

Initiate the automated device, causing it to inflate and then deflate.

The device typically shows the blood pressure recording on an external display.

Wait 2 minutes and obtain a second blood pressure measurement. If the measurements have
greater than a 5 mmHg difference, then readings should continue to be obtained until there are 2
consecutive stable measurements. An average of the 2 stable measurements should be
recorded as the patient’s blood pressure.

Wait another 1-2 minutes and repeat steps 3-7 to measure the blood pressure in the patient’s
opposite arm. If a measurement discrepancy exists between the 2 arms, then the arm with the
highest measurement should be used.

When recording the blood pressure measurement, note not only the pressure but also which arm
was used, the arm position, and the cuff size used.

When obtaining pressure reading using a sphygmomanometer and doppler, begin the same way but
instead of using a stethoscope, use conduction gel and a doppler probe. Place the probe on the
brachial or radial artery of the arm with the cuff and inflate until you obliterate the pulse on the doppler.
Go 20–30mmHg above the pressure at which the pulse was obliterated. Slowly deflate, listening for
the same Korotkoff sounds. This technique is especially useful in vasculopathic patients and those in
circulatory distress.

Complications
Complications are minimal with measuring the blood pressure. Complications that can occur include
discomfort to the arm and possible petechiae in patients taking anti-platelet agents.

Patient Education
The patient should be given the results of their blood pressure measurement. If the pressure is above
normal (typically defined as a measurement ≥120/80) the patient should be advised to follow up with
their health care provider. If the patient is demonstrating any signs of Hypertensive Emergencies they
should be referred immediately to a physician or emergency room.

Device Summary
Stethoscope or doppler and a blood pressure cuff with a mercury or aneroid sphygmomanometer, or
automated oscillometric blood pressure measuring device.

Diagnostic Testing Summary

For manual blood pressure, the summary is as follows:

Choose an adequate cuff size based on the patient’s arm size.

Place the chosen cuff on either the patient’s arm.

Place the stethoscope over the brachial artery.

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Inflate the cuff to a pressure of 30 mmHg above the level at which the radial pulse is no longer
palpable.

While slowly deflating the cuff, listen for Korotkoff phase I while watching the blood pressure
gauge. Record the measurement from the sphygmomanometer when Korotkoff phase I is
auscultated. This represents the patient’s systolic blood pressure.

While watching the sphygmomanometer, continue to slowly deflate the cuff, listening until a
pulse is no longer auscultated (Korotkoff phase V). Record the measurement from the
sphygmomanometer at the onset of Korotkoff phase V. This represents the patient’s diastolic
blood pressure.

Record the blood pressure, arm used, the arm position, and the cuff size used.

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